Cost of preventing variceal rebleeding with transjugular intrahepatic portal systemic shunt and distal splenorenal shunt

doi:10.1016/j.jhep.2007.08.014

Journal of Hepatology

Volume 48, Issue 3, March 2008, Pages 407-414

https://doi.org/10.1016/j.jhep.2007.08.014 Get rights and content

Background/Aims

We examined the cost and cost effectiveness of distal splenorenal shunt (DSRS) and transjugular intrahepatic portosystemic shunt (TIPS) in the prevention of variceal rebleeding.

Methods

Patients participated in a randomized controlled trial comparing DSRS to TIPS. Quality of life (QOL) was measured using SF-36 preceding randomization and yearly thereafter. Cost utility analysis was performed using TreeAge DATA^®. Costs for both in- and out-patient events and interventions were obtained for each patient. Costs using coated stents were estimated using different rates of stenosis. Incremental cost effectiveness ratios (ICERs) were determined at 1, 3 and 5 years.

Results

The average yearly costs of managing patients after TIPS and DSRS over 5 years were similar, $16,363 and $13,492, respectively. Cost of TIPS for surviving patients exceeded the cost of DSRS at years 3 and 5 but not significantly. ICERs per life saved favored TIPS at year 5 ($61,000). If coated rather than bare stents were used the cost effectiveness of TIPS increased slightly.

Conclusions

TIPS is as effective as DSRS in preventing variceal rebleeding and may be more cost effective. TIPS, in all aspects, is equal to DSRS in the prevention of variceal rebleeding in patients who are medical failures.

Introduction

Variceal bleeding is one of the most serious complications of portal hypertension occurring in one-third of patients with cirrhosis [1]. Although outcome from variceal bleeding has improved there is still significant morbidity and mortality associated with each episode of bleeding [2], [3]. Patients with variceal bleeding can be managed with either pharmacologic or endoscopic therapy to prevent rebleeding. However, 20–30% of patients will rebleed despite these therapies leading to variceal decompression as the only effective alternative [4], [5].

A surgically created shunt, such as the distal splenorenal shunt (DSRS), has been considered the most effective method for preventing variceal rebleeding [6], [7], [8], [9], [10]. More recently variceal decompression can also be performed less invasively by placing a stent within the liver that connects the portal vein to the hepatic vein (transjugular intrahepatic portosystemic shunt-TIPS) leading to decompression of the entire portal system and prevention of rebleeding [6], [11], [12], [13], [14]. Although TIPS may be the preferred approach in compensated and decompensated patients due to availability and efficacy [6], [11], it is unknown whether TIPS is as cost effective as shunts.

The costs associated with use of medical therapy vs. TIPS in the prevention of rebleeding have been investigated using a modeling approach. Total annual costs with TIPS were slightly greater than with endoscopic therapy but the incremental cost effectiveness ratio (ICER) per variceal bleed prevented favored the TIPS treatment strategy in one report whereas in another report band ligation plus a beta-blocker dominated all other forms of therapy [13], [15]. The difficulty with both of these modeling studies is that the outcome of the analysis was dependent upon the assumptions chosen about the bleeding risk with each form of therapy. Hence it would be beneficial to obtain outcome and associated cost data from a controlled trial with data obtained prospectively. In the recently completed and published controlled trial comparing TIPS to DSRS such data were obtained [6]. The goal of this analysis was to compare the cost and cost effectiveness of these two approaches.

Section snippets

Patients and statistical calculations

Details of the study are in the recently published report describing a prospective randomized controlled clinical trial for patients with Child–Pugh class A and B cirrhosis who had variceal rebleeding refractory to medical therapy [6]. Seventy-three patients received a DSRS and 67 a TIPS with a mean follow-up ranging 46 ± 26 months. Data collected from the participating sites were entered and stored in an Oracle database. Data management was conducted using Oracle and data analyses performed

Results

The initial cost of the two procedures was $21,607 for TIPS and $28,734 for DSRS. Table 1 contains the costs associated with patients who were alive at each time point. The costs associated with each procedure are shown for in-patient care, out-patient care, laboratory tests and medications during the 5 years of follow-up. Fifty-eight percent of TIPS patients and fifty percent of DSRS patients required re-hospitalization during the first year of follow-up and the hospitalization costs for TIPS

Discussion

This is the first study to assess prospectively the resource utilization of preventing rebleeding from esophageal varices treated by variceal decompression using either a TIPS or DSRS. We feel this study provides a unique view of the cost of caring for patients over a 5 year period with well-compensated cirrhosis who bled from varices. In addition, QOL data were obtained prospectively on all patients. Because these data were obtained prospectively no assumptions were needed as to incidence of

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Cited by (47)

Nonendoscopic management of acute esophageal variceal bleeding
2017, Techniques in Gastrointestinal Endoscopy
Citation Excerpt :
Stent placement is not useful for isolated gastric varices. Both TIPS and surgical shunts are extremely effective in controlling variceal bleeding (up to 95% success rate), although surgical shunts are rarely performed due to the less invasive nature and cost effectiveness of TIPS [46]. Despite the high efficacy of TIPS in controlling bleeding, patient mortality is still high (30%-50%) when TIPS is used as rescue therapy, usually as a consequence of further deterioration in the patient’s clinical condition from failure to control initial bleeding or early rebleeding and the possible complications developed during this period (eg, bacterial infections, liver decompensation, and renal failure).
Acute esophageal variceal bleeding is a life-threatening complication of portal hypertension in patients with liver cirrhosis. Its management has improved over the past several years, leading to a significant reduction in rebleeding episodes and in bleeding-related deaths. Although endoscopic therapy is an integral part in the management of the acute variceal bleeder, pharmacologic and radiologic therapies are important interventions, in addition to optimal supportive care. Herein, we highlight the nonendoscopic management of acute esophageal variceal bleeding.
Chapter 85-Portal hypertensive bleeding: The place of portosystemic shunting
2016, Blumgart's Surgery of the Liver, Biliary Tract and Pancreas: Sixth Edition
Twenty-five years after the first TIPS in Spain
2016, Radiologia
La incorporación, hace ya 25 años, de la derivación portosistémica percutánea intrahepática (conocida por todos como TIPS) ha supuesto un indudable avance terapéutico en el manejo de los pacientes con sintomatología derivada de la hipertensión portal. En este artículo se pretende recordar sus orígenes así como las innovaciones técnicas posteriores que fueron añadiéndose progresivamente. Con la implantación de las prótesis cubiertas, que enfundan el trayecto parenquimatoso, se ha conseguido asegurar la permeabilidad a largo plazo de la conexión, con lo que disminuyen las necesidades de reintervención. Las sólidas evidencias obtenidas desde valiosas publicaciones sitúan el TIPS en un lugar preferente entre el compendio terapéutico de una gran variedad de situaciones clínicas asociadas a la presencia de hipertensión portal.
The incorporation, 25 years ago, of transjugular intrahepatic portosystemic shunting, better known by the acronym TIPS, represents an indisputable improvement in the treatment and management of patients with symptoms due to portal hypertension. This article discusses the origins of the technique and the technical innovations that have been progressively added through the years. The implantation of coated stents, which protect the stent from processes in the parenchymal track that can lead to stenosis, have helped ensure long-term patency, thus reducing the need for reintervention. Solid evidence from valuable publications has situated TIPS at the forefront of the treatment options in a wide variety of clinical situations associated with portal hypertension.
Portosystemic Shunts: Stable Utilization and Improved Outcomes, Two Decades After the Transjugular Intrahepatic Portosystemic Shunt
2015, Journal of the American College of Radiology
The aim of this study was to assess national trends in utilization, demographics, hospital characteristics, and outcomes of patients undergoing surgical or percutaneous portal decompression since the introduction of transjugular intrahepatic portosystemic shunts (TIPS).
A retrospective analysis of patients undergoing surgical portal decompression and TIPS procedures was conducted using Medicare Physician/Supplier Procedure Summary Master Files from January 2003 through December 2013 and National (Nationwide) Inpatient Sample data from 1993, 2003, and 2012. Utilization rates normalized to the annual number of Medicare enrollees, estimated means, and 95% confidence intervals were calculated.
The Medicare total annual utilization rate per million for all portosystemic decompression procedures decreased by 6.5% during the study period, from 15.3 in 2003 to 14.3 in 2013. TIPS utilization increased by 19.4% (from 10.3 to 12.3 per million), whereas open surgical shunt utilization decreased by 60.0% (from 5.0 to 2.0 per million). TIPS procedures represented 86% of all procedures in 2013. From 1993 to 2012, mean age increased slightly (from 53.0 to 55.5 years, P < .05). The percentage of procedures performed at teaching hospitals increased, whereas in-hospital mortality and length of stay decreased by 42% (P < .05) and 20% (P < .05), respectively. Of factors evaluated, the performance of procedures on an elective basis was the most influential on in-hospital mortality (P < .01, all years studied) and length of stay (P < .0001, all years studied).
Approximately two decades after the introduction of TIPS, the utilization of all portal decompression procedures has remained relatively stable. The TIPS procedure represents the dominant portal decompression technique. In-hospital mortality and mean length of stay after decompression have decreased, partially because of the performance of procedures during elective admissions.
Interventional radiology delivers high-value health care and is an imaging 3.0 vanguard
2015, Journal of the American College of Radiology
Citation Excerpt :
Given a low rebleed rate comparable to that with surgical shunting [17,18], and the high mortality associated with rebleeding [19,20], TIPS has been particularly important for poor surgical candidates and in acute settings. In the past, the applicability of TIPS has been limited by cost, high rates of hepatic encephalopathy, and complications requiring reintervention [15], but recent studies have demonstrated equal or superior cost-effectiveness [21-24], justifying an increase in its implementation. Additionally, compared with surgical shunts, which may complicate liver transplantation, successful TIPS can be performed without affecting a patient’s transplant status or subsequent surgical procedure [25].
Given the changing climate of health care and the imperative to add value, radiologists must join forces with the rest of medicine to deliver better patient care in a more cost-effective, evidence-based manner. For several decades, interventional radiology has added value to the health care system through innovation and the provision of alternative and effective minimally invasive treatments, which have decreased morbidity, mortality, and overall cost. The clinical practice of interventional radiology embodies many of the features of Imaging 3.0, the program recently launched by the ACR. We provide a review of some of the major contributions made by interventional radiology and offer general principles from that experience, which are applicable to all radiologists.
Mexican consensus on portal hypertension
2013, Revista de Gastroenterologia de Mexico
El objetivo del Consenso Mexicano de Hipertensión Portal fue desarrollar un documento guía para facilitar la práctica clínica en eventos clave del paciente con hipertensión portal y sangrado variceal. El panel de expertos incluyó gastroenterólogos, hepatólogos y endoscopistas mexicanos distinguidos por su trayectoria profesional. El documento exploró temas de interés en los siguientes módulos: profilaxis preprimaria y primaria, hemorragia variceal aguda y profilaxis secundaria. El manejo del sangrado variceal ha mejorado notablemente en años recientes. La información actual indica que el manejo general del paciente cirrótico con sangrado variceal se debe realizar por un equipo multidisciplinario, lo que tiene un papel importante en el desenlace final. Se recomienda combinar la terapia farmacológica y endoscópica en el manejo inicial; los fármacos vasoactivos se deben iniciar cuanto antes ante la sospecha de sangrado de origen variceal y mantenerse durante 5 días. Después de estabilizar al paciente, se realizará la endoscopia diagnóstica de urgencia por un endoscopista calificado, y se dará el tratamiento endoscópico variceal correspondiente. La profilaxis con antibiótico se debe considerar como parte integral del tratamiento, iniciarse desde el ingreso hospitalario y mantenerse durante 5 días. En caso de falla terapéutica, las terapias de rescate se deben iniciar de inmediato; tomando en cuenta que las terapias de derivación mediante radiolgía de intervención son muy efectivas en el control del sangrado variceal refractario. Estas guías están basadas en la mejor evidencia disponible sobre hipertensión portal, y están dirigidas a lograr una mayor eficacia clínica.
The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.

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^☆: The authors declare that they do not have anything to disclose regarding conflict of interest with respect to this manuscript. NIH funded study NIDDK DK050680. Clinical Trials Gov Identifier NCT 00006161.

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Cost of preventing variceal rebleeding with transjugular intrahepatic portal systemic shunt and distal splenorenal shunt☆

Background/Aims

Methods

Results

Conclusions

Introduction

Section snippets

Patients and statistical calculations

Results

Discussion

Gastroenterology

Gastroenterology

J Clin Epidemiol

J Clin Epidemiol

J Clin Epidemiol

J Health Econ

Gastroenterology

Diagnosis and treatment of gastrointestinal bleeding secondary to portal hypertension

Am J Gastroenterol

Improving prognosis following a first variceal haemorrhage over four decades

Gut

Improved patient survival after acute variceal bleeding: a multicenter, cohort study

Am J Gastroenterol

Gastroesophageal variceal hemorrhage

N Engl J Med

The treatment of portal hypertension: a meta-analytic review

Hepatology

Surgical shunts and TIPS for variceal decompression in the 1990’s

Surgery

The changing spectrum of treatment for variceal bleeding

Ann Surg

Distal splenorenal shunt: role, indications, and utility in the era of liver transplantation

Arch Surg